Choice A rationale

Pharmacists are healthcare professionals who specialize in the preparation and dispensing of medications. While they have extensive knowledge about drugs and their interactions, they are not typically responsible for providing dietary or nutrition education to clients with diabetes. Their primary role is to ensure that patients receive the correct medications and understand how to take them properly.

Choice B rationale

Radiologic technologists are trained to perform diagnostic imaging examinations, such as X- rays, MRI scans, and CT scans. They do not have the expertise or training to provide dietary or nutrition education to clients with diabetes. Their focus is on capturing accurate images to assist in the diagnosis and treatment of medical conditions.

Choice C rationale

Respiratory therapists specialize in the assessment and treatment of patients with breathing or cardiopulmonary disorders. They are skilled in providing respiratory care, such as administering oxygen therapy and managing ventilators. However, they do not have the training or expertise to provide dietary or nutrition education to clients with diabetes.

Choice D rationale

Registered dietitians are healthcare professionals who specialize in nutrition and dietary management. They are trained to provide individualized dietary education and counseling to clients with various medical conditions, including diabetes. Registered dietitians can help clients understand how to manage their blood glucose levels through proper nutrition and meal planning, making them the most appropriate choice for providing dietary or nutrition education to clients with diabetes.

Choice A rationale

Planning is the phase of the nursing process where the nurse develops a plan of care based on the assessment data and identified nursing diagnoses. It involves setting goals and determining the appropriate interventions to achieve those goals. In this scenario, the nurse is not developing a plan but rather observing the effects of an intervention that has already been implemented.

Choice B rationale

Assessment is the initial phase of the nursing process where the nurse collects and analyzes data about the client’s health status. This includes gathering information through observation, interviews, physical examinations, and diagnostic tests. In this scenario, the nurse is not collecting new data but rather observing the outcome of a previously administered medication.

Choice C rationale

Evaluation is the phase of the nursing process where the nurse assesses the client’s response to the interventions and determines whether the goals of care have been met. In this scenario, the nurse is evaluating the effectiveness of the antihypertensive medication by noting the decrease in the client’s blood pressure. This assessment helps determine if the medication is achieving the desired therapeutic effect.

Choice D rationale

Analysis is the phase of the nursing process where the nurse interprets the assessment data to identify the client’s health problems and needs. It involves critical thinking and clinical judgment to determine the underlying causes of the client’s condition. In this scenario, the nurse is not analyzing data but rather evaluating the outcome of an intervention.

Choice A rationale

Providing all information at once to ensure understanding is not an effective teaching strategy, especially for clients newly diagnosed with diabetes. This approach can overwhelm the client and make it difficult for them to retain and comprehend the information. Effective teaching involves breaking down the information into manageable segments and reinforcing key concepts over time.

Choice B rationale

Avoiding repetition to prevent boredom is not an effective teaching strategy. Repetition is essential for reinforcing important concepts and ensuring that the client fully understands the information. Repetition helps to reinforce learning and improve retention, especially for complex topics such as diabetes management.

Choice C rationale

Tailoring teaching strategies to the client’s learning style is the most effective approach for teaching clients newly diagnosed with diabetes. Each client has a unique learning style, and adapting the teaching methods to match their preferences can enhance understanding and retention. This personalized approach ensures that the client receives the information in a way that is most meaningful and effective for them.

Choice D rationale

Using medical terminology to enhance credibility is not an effective teaching strategy for clients newly diagnosed with diabetes. Medical jargon can be confusing and intimidating for clients, making it difficult for them to understand the information. It is important to use clear, simple language that the client can easily comprehend.

Choice A rationale

Feeding a stroke client who has difficulty in swallowing is a task that requires careful attention to prevent aspiration and choking. While this task is important, it can be delegated to a trained nursing assistant or a licensed practical nurse (LPN) under the supervision of an RN. The RN should focus on tasks that require higher levels of clinical judgment and expertise.

Choice B rationale

Completing a sterile dressing change to a pressure ulcer is a task that requires the expertise and clinical judgment of an RN. Sterile dressing changes involve maintaining a sterile field, assessing the wound, and applying appropriate dressings. This task is critical for preventing infection and promoting wound healing, making it appropriate for the RN to perform.

Choice C rationale

Reapplying a condom catheter for a client with urinary incontinence is a routine procedure that can be delegated to a trained nursing assistant or an LPN. This task does not require the advanced clinical skills and judgment of an RN, allowing the RN to focus on more complex and critical tasks.

Choice D rationale

Reinforcing teaching with a client who is learning how to administer insulin is an important task, but it can be delegated to an LPN under the supervision of an RN. The RN should prioritize tasks that require higher levels of clinical expertise and judgment, such as sterile dressing changes and complex assessments.

Choice A rationale

A common adverse event that occurs frequently is not considered a sentinel event. Sentinel events are rare and unexpected occurrences that result in severe harm or death. Common adverse events, while important to address, do not meet the criteria for sentinel events.

Choice B rationale

A minor incident that does not require reporting is not considered a sentinel event. Sentinel events are serious and significant occurrences that require immediate investigation and response. Minor incidents, while important to address, do not meet the criteria for sentinel events.

Choice C rationale

An unexpected occurrence involving death or serious physical or psychological injury is the definition of a sentinel event. These events are significant and require immediate investigation and response to prevent recurrence. Sentinel events signal the need for a thorough review of the processes and systems involved to identify and address the root causes.

Choice D rationale

A situation where the patient experiences temporary discomfort is not considered a sentinel event. Sentinel events involve severe and lasting harm, such as death or permanent injury.Temporary discomfort, while important to address, does not meet the criteria for sentinel events.

Choice A rationale

Quasi-experimental research involves the manipulation of an independent variable to determine its effect on a dependent variable, similar to experimental research. However, quasi-experimental designs lack random assignment to groups, which can limit the ability to infer causality. Despite this limitation, quasi-experimental designs are valuable for studying causal relationships in real-world settings where random assignment is not feasible.

Choice B rationale

Correlational research examines the relationship between two or more variables without manipulating any variables. It does not involve the manipulation of an independent variable or the use of control groups, making it distinct from quasi-experimental research.

Choice C rationale

Qualitative research focuses on exploring and understanding the meaning and experiences of individuals through methods such as interviews, observations, and content analysis. It does not involve the manipulation of variables or the use of experimental designs, making it distinct from quasi-experimental research.

Choice D rationale

Quantitative research involves the collection and analysis of numerical data to identify patterns, relationships, and trends. While quasi-experimental research is a type of quantitative research, not all quantitative research involves quasi-experimental designs. Quantitative research can also include experimental, correlational, and descriptive designs.

Choice A rationale

Confining a patient to a room without provisions for their care is not the best definition of false imprisonment. While it may be considered neglect or abuse, false imprisonment specifically involves restraining a person against their will without legal justification.

Choice B rationale

Restraining a patient against their will is the correct definition of false imprisonment. False imprisonment occurs when a person is intentionally confined or restrained without their consent and without legal authority.

Choice C rationale

Applying physical restraints to prevent falls is not considered false imprisonment if done with proper consent and following legal and medical guidelines. It is a safety measure, not an unlawful restraint.

Choice D rationale

Implementing a care plan without patient consent may be considered a violation of patient rights, but it does not fit the definition of false imprisonment. False imprisonment specifically involves physical restraint or confinement.

Choice A rationale

Providing written handouts for reference can be helpful, but it is not the most effective strategy for fall prevention education among older adults. Interactive methods are generally more engaging and effective.

Choice B rationale

Using complex medical terminology to explain concepts is not effective for older adults. It can lead to confusion and misunderstanding, reducing the effectiveness of the education.

Choice C rationale

Using interactive demonstrations and group discussions is the most effective strategy for teaching fall prevention to older adults. These methods engage the audience, making the information more relatable and easier to understand.

Choice D rationale

Speaking quickly to maintain attention is not effective for older adults. It can lead to information being missed or misunderstood. Clear, slow, and interactive communication is more effective.

Choice A rationale

Tertiary prevention involves managing and rehabilitating patients with established diseases to prevent complications and improve quality of life. Referring a client to a specialist for further evaluation does not fit this category.

Choice B rationale

Primary prevention aims to prevent the onset of disease by reducing risk factors and promoting health. Referring a client to a specialist for further evaluation is not primary prevention.

Choice C rationale

Secondary prevention involves early detection and treatment of disease to prevent progression. Referring a client to a specialist for further evaluation fits this category as it aims to identify and address health issues early.

Choice D rationale

“Disease process” is not a recognized level of prevention. The correct levels are primary, secondary, and tertiary.

Choice A rationale

Implementing the order immediately without verifying is unsafe and can lead to errors. Nurses must ensure clarity and accuracy before carrying out any orders.

Choice B rationale

Writing down the order and reading it back to the physician is the correct action. This ensures that the order is understood correctly and reduces the risk of errors.

Choice C rationale

Asking the physician to repeat the order multiple times is unnecessary and can be seen as unprofessional. Writing down and reading back the order is a more effective method.

Choice D rationale

Ignoring the order if it seems unclear is not appropriate. Nurses have a responsibility to clarify any unclear orders to ensure patient safety.

Choice A rationale

Disease surveillance is not a level of prevention. It is an activity that can be part of different levels of prevention.

Choice B rationale

Tertiary prevention involves managing and rehabilitating patients with established diseases. Disease surveillance does not fit this category.

Choice C rationale

Primary prevention aims to prevent the onset of disease. Disease surveillance is not primary prevention.

Choice D rationale

Secondary prevention involves early detection and treatment of disease. Disease surveillance fits this category as it aims to monitor and identify health issues early.

Choice A rationale

Asking why the patient hasn’t shared their feelings with their family is not therapeutic. It can come across as judgmental and may not encourage open communication.

Choice B rationale

Asking the patient to tell more about how they are feeling is therapeutic. It shows empathy and encourages the patient to express their emotions, which can be helpful in processing their feelings.

Choice C rationale

Telling the patient they are probably very depressed is not therapeutic. It labels their feelings and may not encourage further discussion.

Choice D rationale

Suggesting the patient talk with their family about their career is not relevant to the patient’s current emotional state and concerns. .

Choice A rationale

The right circumstance refers to the appropriate setting and resources being available for the task to be delegated. It ensures that the situation is suitable for delegation, considering factors such as the patient’s condition and the complexity of the task. However, this is not the focus of the question, which is about the nurse’s demonstration during delegation.

Choice B rationale

The right communication involves clear, concise, and complete instructions given to the assistive personnel. It ensures that the delegatee understands the task, the expected outcomes, and any specific instructions or precautions. This is the correct answer because the nurse is demonstrating effective communication during the delegation process.

Choice C rationale

The right supervision refers to the appropriate monitoring and evaluation of the task being performed by the delegatee. It ensures that the nurse provides guidance, support, and feedback as needed. While important, this is not the focus of the question, which is about the nurse’s demonstration during delegation.

Choice D rationale

The right task refers to the appropriateness of the task being delegated, ensuring it is within the delegatee’s scope of practice and competency level. It ensures that the task is suitable for delegation. However, this is not the focus of the question, which is about the nurse’s demonstration during delegation.

Choice A rationale

Ignoring the comment and documenting “No Known Allergies” (NKA) is incorrect because it disregards the client’s report of an allergy. This action could lead to potential harm if the client is indeed allergic to codeine.

Choice B rationale

Asking the client why they think it is an allergy is not the best response. It may come across as dismissive and does not provide the nurse with specific information about the client’s allergic reaction.

Choice C rationale

Telling the client not to worry and that they will be okay if they take codeine with food is incorrect. This response is dismissive of the client’s concern and does not address the potential for an allergic reaction.

Choice D rationale

Asking the client what symptoms they experience with codeine is the best response. It allows the nurse to gather specific information about the client’s allergic reaction, which is crucial for safe medication administration.

Choice A rationale

Assuming the client understands and proceeding with the regimen is incorrect. It does not verify the client’s understanding and could lead to non-compliance or errors in medication administration.

Choice B rationale

Repeating the instructions using different words may help, but it does not ensure that the client has understood the information. It is important to verify understanding through the client’s response.

Choice C rationale

Documenting that the client has full understanding of the regimen without verification is incorrect. It assumes understanding without confirmation, which could lead to potential errors.

Choice D rationale

Asking the client to verbally respond to the questions is the best action. It ensures that the client has understood the information and allows the nurse to clarify any misunderstandings.

Choice A rationale

A 5-year-old patient admitted yesterday with pneumonia may require frequent assessments and interventions that are within the scope of practice for an LPN. However, the complexity of care for a newly admitted patient with a potentially unstable condition may be better suited for an RN.

Choice B rationale

A 78-year-old female with osteoporosis who needs assistance performing range of motion exercises and ambulating with a walker can be managed by an LPN. These tasks are within the LPN’s scope of practice and do not require the higher level of assessment and decision-making skills of an RN.

Choice C rationale

A 78-year-old patient newly admitted with congestive heart failure requires complex assessments, monitoring, and interventions that are within the scope of practice for an RN. The RN’s advanced skills and knowledge are necessary to manage the patient’s condition effectively.

Choice D rationale

A 34-year-old patient post knee arthroscopy who requires reinforced crutch walking can be managed by an LPN. These tasks are within the LPN’s scope of practice and do not require the higher level of assessment and decision-making skills of an RN.

Choice A rationale

Planning involves setting goals and determining the appropriate interventions to achieve those goals. It is not the step being performed when changing a wound dressing.

Choice B rationale

Evaluation involves assessing the effectiveness of the interventions and determining if the goals have been met. It is not the step being performed when changing a wound dressing.

Choice C rationale

Assessment involves gathering data about the client’s condition. While assessment is an ongoing process, it is not the primary step being performed when changing a wound dressing.

Choice D rationale

Implementation involves carrying out the planned interventions. Changing a wound dressing is an example of implementing a nursing intervention.

Choice A rationale

Using a nicotine patch to assist in smoking cessation involves the psychomotor domain of learning, which focuses on physical skills and actions.

Choice B rationale

Starting to use nicotine gum as part of the cessation plan also involves the psychomotor domain of learning, which focuses on physical skills and actions.

Choice C rationale

Encouraging the client to share their feelings about smoking involves the affective domain of learning, which focuses on emotions, attitudes, and values.

Choice D rationale

Explaining the benefits of smoking cessation involves the cognitive domain of learning, which focuses on knowledge, understanding, and intellectual skills.

Choice A rationale

Sitting quietly and engaging the client can be supportive, but it may not be sufficient to establish rapport. While presence is important, it lacks the active engagement and therapeutic techniques needed to build a connection.

Choice B rationale

Using open-ended questions starting with “I want time to think and reflect” is not appropriate in this context. Open-ended questions are useful, but the phrasing here is not conducive to therapeutic communication and may confuse the client.

Choice C rationale

Using therapeutic communication techniques is the correct approach. These techniques include active listening, empathy, and validation, which are essential for building rapport and trust with the client. They help the client feel understood and supported.

Choice D rationale

Offering tissues and a comforting presence is supportive but not sufficient on its own. While it shows empathy, it does not actively engage the client in a therapeutic manner to establish rapport.

Choice A rationale

Keeping the fluorescent ceiling light on at night can cause glare and disrupt sleep, which is not ideal for safety. It may also create shadows that can be disorienting.

Choice B rationale

Keeping the walker at the end of the bed is not practical. The walker should be within easy reach to ensure the client can use it immediately upon getting out of bed.

Choice C rationale

Placing grip bars in the shower is a correct and effective safety measure. Grip bars provide stability and support, reducing the risk of falls while bathing.

Choice D rationale

Placing an area rug at the entry of the bathroom can be a tripping hazard. Rugs can slip or bunch up, increasing the risk of falls.

Choice A rationale

Providing the instructions in an audio format is a suitable solution for clients who are unable to read. It ensures they can understand and follow the medication instructions accurately.

Choice B rationale

Ensuring the client has someone to assist with reading the instructions is helpful but not always reliable. The client may not always have someone available to assist them.

Choice C rationale

Using larger print for the instructions can help, but it may not be sufficient for clients with severe visual impairments.

Choice D rationale

Teaching the client to use a magnifying glass is a practical solution, but it may not be as effective as providing audio instructions, especially if the client has difficulty using the magnifying glass.

Choice A rationale

Maintaining confidentiality of patient information is crucial, but it falls under the principle of confidentiality, not fidelity.

Choice B rationale

Remaining loyal and faithful to one’s personal beliefs and values is important, but it is not the primary focus of fidelity in nursing practice.

Choice C rationale

Upholding professional obligations and commitments is the essence of fidelity in nursing. It involves being faithful to the promises made to patients and the profession, ensuring trust and integrity in nursing practice.

Choice D rationale

Ensuring equitable distribution of healthcare resources is related to the principle of justice, not fidelity.

Choice A rationale

The route of administration is important, but it is not the only missing element in this prescription.

Choice B rationale

The frequency of administration is missing, which is crucial for ensuring the medication is given at the correct intervals. Without this information, the prescription is incomplete and can lead to medication errors.

Choice C rationale

The patient’s name is essential, but it is not the only missing element in this prescription.

Choice D rationale

The prescriber’s signature is important for validating the prescription, but the frequency of administration is the critical missing element in this context. .

Choice A rationale

Assessing the client’s readiness for learning is important, but it is not the priority action when teaching a client to administer insulin. The priority is to ensure the client can perform the task correctly to manage their condition effectively.

Choice B rationale

Asking the client to demonstrate the injection technique is the correct answer. This action ensures that the client has understood the instructions and can perform the task correctly, which is crucial for their safety and effective management of their diabetes.

Choice C rationale

Showing the client how to draw up the insulin in a syringe is an important step in the teaching process, but it is not the priority action. The priority is to ensure the client can perform the injection technique correctly.

Choice D rationale

Developing short-term goals for the client in the teaching plan is important for overall education and management, but it is not the priority action when teaching a client to administer insulin. The priority is to ensure the client can perform the injection technique correctly.

Choice A rationale

Documenting the application of the medication is important for maintaining accurate medical records, but it is not the priority action when a patient is receiving a new medication.

Choice B rationale

Informing the patient about potential side effects is the correct answer. This action ensures that the patient is aware of what to expect and can report any adverse reactions promptly, which is crucial for their safety.

Choice C rationale

Checking the patient’s vital signs frequently is important, but it is not the priority action when a patient is receiving a new medication. The priority is to inform the patient about potential side effects.

Choice D rationale

Leaving the patient alone to rest is not appropriate when a patient is receiving a new medication. The nurse should monitor the patient and inform them about potential side effects.